Generalized Anxiety Disorder
DSM-II In DSM-II, this disorder is called Anxiety neurosis This neurosis is characterized by anxious over-concern extending to panic and frequently associated with somatic symptoms. Unlike Phobic neurosis, anxiety may occur under any circumstances and is not restricted to specific situations or objects. This disorder must be distinguished from normal apprehension or fear, which occurs in realistically dangerous situations. DSM-III Diagnostic Criteria A'. Generalized, persistent anxiety is manifested by symptoms from three of the following four categories: # ''motor tension: shakiness, jitteriness, jumpiness, trembling, tension, muscle aches, fatigability, inability to relax, eyelid twitch, furrowed brow, strained face, fidgeting, restlessness, easy startle # autonomic hyperactivity: sweating, heart pounding or racing, cold, clammy hands, dry mouth, dizziness, light-headedness, paresthesias (tingling in hands or feet), upset stomach, hot or cold spells, frequent urination, diarrhea, discomfort in the pit of the stomach, lump in the throat, flushing, pallor, high resting pulse and respiration rate # apprehensive expectation: anxiety, worry, fear, rumination, and anticipation of misfortune to self or others # vigilance and scanning: hyperattentiveness resulting in distractibility, difficulty in concentrating, insomnia, feeling "on edge," irritability, impatience '''B. The anxious mood has been continuous for at least one month. C'''. Not due to another mental disorder, such as a Depressive Disorder or Schizophrenia. '''D. At least 18 years of age. Differential Diagnosis Physical disorders and Organic Mental Disorders Physical disorders, such as hyperthyroidism, and Organic Mental Disorders, such as Caffeine Intoxication, must be ruled out. Adjustment Disorder In Adjustment Disorder with Anxious Mood, the full symptom picture required to meet the criteria for Generalized Anxiety Disorder is generally not present, the duration of the disturbance is usually less than a month, and a psychosocial stressor must be recognized. Other mental disorders In Schizophrenia, Depressive Disorders, Hypochondriasis, Obsessive Compulsive Disorder, and many other mental disorders, generalized and persistent anxiety is often a prominent symptom. The diagnosis of Generalized Anxiety Disorder is not made if the anxiety is judged to be due to another mental disorder. Panic Disorder In Panic Disorder there is often severe chronic anxiety between panic attacks. If the panic attacks are overlooked, an incorrect diagnosis of Generalized Anxiety Disorder may be made. DSM-IV Diagnostic Criteria A'''. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). '''B. The person finds it difficult to control the worry. C'''. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). '''Note: Only one item is required in children. # restlessness or feeling keyed up or on edge # being easily fatigued # difficulty concentrating or mind going blank # irritability # muscle tension # sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) D'''. The focus of the anxiety and worry is not confined to features of a mental disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder. '''E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. F'''. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder. '''Differential Diagnosis Anxiety Disorder Due to a General Medical Condition and Substance-Induced Anxiety Disorder Generalized Anxiety Disorder must be distinguished from an Anxiety Disorder Due to a General Medical Condition. The diagnosis is Anxiety Disorder Due to a General Medical Condition if the anxiety symptoms are judged to be a direct physiological consequence of a specific general medical condition (e.g., pheochromocytoma, hyperthyroidism). This determination is based on history, laboratory findings, or physical examination. A Substance-Induced Anxiety Disorder is distinguished from Generalized Anxiety Disorder by the fact that a substance (i.e., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically related to the anxiety disturbance. For example, severe anxiety that occurs only in the context of heavy coffee consumption would be diagnosed as Caffeine-Induced Anxiety Disorder, With Generalized Anxiety. Other mental disorders When another mental disorder is present, an additional diagnosis of Generalized Anxiety Disorder should be made only when the focus of the anxiety and worry is unrelated to the other disorder, that is, the excessive worry is not restricted to having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), gaining weight (as in Anorexia Nervosa), having a serious illness (as in Hypochondriasis), having multiple physical complaints (as in Somatization Disorder), or to concerns about the welfare of close relations or being away from them or from home (as in Separation Anxiety Disorder). For example, the anxiety present in Social Phobia is focused on upcoming social situations in which the individual must perform or be evaluated by others, whereas individuals with Generalized Anxiety Disorder experience anxiety whether or not they are being evaluated. Obsessive-Compulsive Disorder Several features distinguish the excessive worry of Generalized Anxiety Disorder from the obsessional thoughts of Obsessive-Compulsive Disorder. Obsessional thoughts are not simply excessive worries about everyday or real-life problems, but rather are ego-dystonic intrusions that often take the form of urges, impulses, and images in addition to thoughts. Finally, most obsessions are accompanied by compulsions that reduce the anxiety associated with the obsessions. Posttraumatic Stress Disorder, Adjustment Disorder, Mood Disorders, and Psychotic Disorders Anxiety is invariably present in Posttraumatic Stress Disorder. Generalized Anxiety Disorder is not diagnosed if the anxiety occurs exclusively during the course of Posttraumatic Stress Disorder. Anxiety may also be present in Adjustment Disorder, but this residual category should be used only when the criteria are not met for any other Anxiety Disorder (including Generalized Anxiety Disorder). Moreover, in Adjustment Disorder the anxiety occurs in response to a life stressor and does not persist for more than 6 months after the termination of the stressor or its consequences. Generalized anxiety is a common associated feature of Mood Disorders and Psychotic Disorder and should not be diagnosed separately if it occurs exclusively during the course of these conditions. Nonpathological anxiety Several features distinguish Generalized Anxiety Disorder from nonpathological anxiety. First, the worries associated with Generalized Anxiety Disorder are difficult to control and typically interfere significantly with functioning, whereas the worries of everyday life are perceived as more controllable and can be put off until later. Second, the worries associated with Generalized Anxiety Disorder are more pervasive, pronounced, distressing, and of longer duration and frequently occur without precipitants. The more life circumstances about which a person worries excessively (finances, children's safety, job performance, car repairs), the more likely the diagnosis. Third, everyday worries are much less likely to be accompanied by physical symptoms (e.g., excessive fatigue, restlessness, feeling keyed up or on edge, irritability), although this is less true of children. DSM-5 Diagnostic Criteria A'''. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). '''B. The individual finds it difficult to control the worry. C'. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): ('Note: Only one item is required in children.) # Restlessness or feeling keyed up or on edge. # Being easily fatigued. # Difficulty concentrating or mind going blank. # Irritability. # Muscle tension. # Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). D'''. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. '''E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F'''. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder). '''Differential Diagnosis Anxiety disorder due to another medical condition The diagnosis of anxiety disorder associated with another medical condition should be assigned if the individual's anxiety and worry are judged, based on history, laboratory findings, or physical examination, to be a physiological effect of another specific medical condition (e.g., pheochromocytoma, hyperthyroidism). Substance/medication-induced anxiety disorder A substance/medication-induced anxiety disorder is distinguished from generalized anxiety disorder by the fact that a substance or medication (e.g., a drug of abuse, exposure to a toxin) is judged to be etiologically related to the anxiety. For example, severe anxiety that occurs only in the context of heavy coffee consumption would be diagnosed as caffeine-induced anxiety disorder. Social anxiety disorder Individuals with social anxiety disorder often have anticipatory anxiety that is focused on upcoming social situations in which they must perform or be evaluated by others, whereas individuals with generalized anxiety disorder worry, whether or not they are being evaluated. Obsessive-compulsive disorder Several features distinguish the excessive worry of generalized anxiety disorder from the obsessional thoughts of obsessive-compulsive disorder. In generalized anxiety disorder the focus of the worry is about forthcoming problems, and it is the excessiveness of the worry about future events that is abnormal. In obsessive-compulsive disorder, the obsessions are inappropriate ideas that take the form of intrusive and unwanted thoughts, urges, or images. Posttraumatic stress disorder and adjustment disorders Anxiety is invariably present in posttraumtic stress disorder. Generalized anxiety disorder is not diagnosed if the anxiety and worry are better explained by symptoms of posttraumatic stress disorder. Anxiety may also be present in adjustment disorder, but this residual category should be used only when the criteria are not met for any other disorder (including generalized anxiety disorder). Moreover, in adjustment disorders, the anxiety occurs in response to an identifiable stressor within 3 months of the onset of the stressor and does not persist for more than 6 months after the termination of the stressor or its consequences. Depressive, bipolar, and psychotic disorders Generalized anxiety/worry is a common associated feature of depressive, bipolar, and psychotic disorders and should not be diagnosed separately if the excessive worry has occurred only during the course of these conditions.